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(11) | EP 1 666 072 A1 |
| (12) | EUROPEAN PATENT APPLICATION |
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| (54) | Method of establishing the optimal radiation dose for a radiopharmaceutical treatment of disease |
| (57) A method for determining the number of millicurie to be administered to a patient
so as to deliver a given centigray (cGy) dose of either the patient's lean body of
the patient's total body. The method includes the steps of injecting a radioactive
tracer into a patient, determining radiation levels in the whole body, calculating
a geometric mean based on the radiation levels, determining the percent-injected activity
remaining in the body at each time point, plotting the percent-injected activity versus
calculated time from infusion on a log-linear graph, determining the effective half-life
and the rate of clearance from the log-linear graph, cross-indexing the effective
half-life vlue with the patient's body weight, and multiplying the determined amount
of therapeutic millicurie per centigray by the amount of desired centigray to be administered. |
BACKGROUND OF THE INVENTION
1. Field of the Invention
[0001] The present invention relates to the administration of radiopharmaceutical compounds for the therapy of disease including cancer. More particularly, the present invention relates to a method of establishing the optimal effective radiation dose for treatment of disease, the method minimizing toxicity while preserving therapeutic activity.
2. Description of the Relevant Art
[0002] Radiopharmaceuticals are compounds composed of radioactive isotopes often bound to other molecules. These radiopharmaceuticals are used in assessing the presence, outline, size, position, or physiology of individual organs or tissues. More significantly for the present invention, radiopharmaceuticals are commonly used in the treatment of disease. For example, radioactive iodine (I-131) is used to treat thyroid cancer or overactive thyroids (Grave's disease). Of considerable importance is the development of monoclonal antibodies having attached radioactive labels. When combined with antibodies that are relatively specific for a particular diseased tissue, such antigen-specific monoclonal antibodies are able to selectively direct comparatively sizable amounts of radiation to the specific disease site. Such treatments are being applied to the treatment of non-Hodgkin's tymphomas, Hodgkin's lymphomas, Hepatoma, colo-rectal cancer, brain tumors, and many other forms of cancer. In addition, the treatments also have the potential to treat other types of disease, including auto-immune conditions such as, for example, Systemic Lupus and Rheumatoid arthritis. Targeted radiopharmaceutical therapy may be ultimately be found to be broadly applicable to a wide variety of neoplastic and benign diseases.
[0003] At present, the radiopharmaceutical is commonly introduced into the blood for ultimate internal distribution through conventionally known methods such as through intravenous, inhalation, or oral administration. A common unit of radioactivity is the millicurie, or mCi.
[0004] The general difficulty of the administration of radiopharmaceuticals for therapy lies in the fact that if the patient is given too much radioactivity, toxicity results. On the other hand, it is necessary to give enough of the radiopharmaceutical so that the disease is successfully treated. The most common specific side effect of radiopharmaceutical treatment is bone marrow suppression or ablation. This is caused by the targeting of the radiopharmaceutical (or the radiolabel) to the bone or bone marrow or is due to circulation of the radioantibody through the blood vessels (including the marrow). In general, this situation could lead to bleeding, infection or death. This side effect (as well as other undesirable side effects) is caused by the inaccuracy of known methods used to determine the radioactive dose for the individual patient. For example, up to a five fold difference in the radiation dose to blood, bone marrow, or body received/mCi of the particular radioantibody administered may exist between patients. (Radiation dose is defined as the total amount of energy per unit mass deposited in an individual as a result of radioactive decay.) These differences are tied to the fact that individuals are physiologically different. Not only are individuals of different sizes and, to some degree, densities, they also differ in abilities to metabolize and clear radiopharmaceuticals. For example, if the radioactivity is attached to a monoclonal antibody, the radioactivity might be eliminated from different patients such that a half life of clearance of radioactivity of three days might be identified in a first patient, while a half life of clearance of radioactivity of six days is identified in a second patient.
[0005] Accordingly, the challenge facing the physician today is determining the correct number of millicuries to be administered to a particular patient having a particular disease at a particular stage of development of that disease. The number of millicuries to be administered is based on the prescription of a given radiation dose to the "whole body" of the patient, which is dependent upon several factors, including the patient's size and the rate of disappearance of radioantibody from the body as determined by direct measurements of the biodistribution of a tracer dose (a small, non-therapeutic quantity) of radioactivity using a gamma camera, probe detector system, or other radiation detection system. Using such an approach, a "whole body radiation dose" can be calculated from the tracer doses, which can be used to predict the radiation dose the "whole body" would receive from subsequent radiopharmaceutical therapy and which allows the radiation dose administered to be effective. Initial results with this approach using the anti-B-1 antibody have shown excellent therapeutic efficacy and modest toxicity. Results of clinical studies with this approach are detailed in NEJM 7:329, pp. 459-465, 1993 (Kaminski et al.), J. Nucl. Med. 35(5), 233P, 1994 (Wahl et al.), and J. Nucl. Med. 35(5), 101P, 1994 (Wahl et al.).
[0006] While this approach to calculating "whole body" radiation dose represents a major improvement over other methods which are not individualized to the patient's individual pharmacology, it still does not fully overcome the difficulties related to the accurate calculation of optimal radiation doses to treat radiosensitive tumors. The inherent failure of this method lies in the fact that the simple assumptions of "whole body" dose are not fully valid in terms of human patient physiology. Accordingly, while radiotoxicity is reduced, it is not fully eliminated or even absolutely minimized. Part of the reason for this failure is that the "whole body" dose approach assumes that a radiopharmaceutical is uniformly distributed throughout the body. There is an assumption underlying this thinking that the body is uniform, and that distribution of chemicals in the body is likewise uniform. This is not the case, as most radiopharmaceuticals, particularly intact monoclonal antibodies, have very limited accumulation in fat tissue compared to considerably greater accumulation in lean body tissue (including bone marrow).
[0007] In an effort to improve the accuracy of radiopharmaceutical mCi dosage, a method has been developed that utilizes a parameter directed to "total body dose-lean" (TBD-lean) to account for the fact that individuals may be modeled as an outer shell of fat (where little radioantibody or radiopharmaceutical accumulation occurs) which surrounds an active lean body mass, including bone marrow.
[0008] By appreciating the fact that in man there is a "lean body" within a "fat" outer shell, a formula may be used to estimate what percentage of the person is fat and what percent of the person is lean. Thereafter, the radioactivity is traced as essentially being distributed uniformly and totally through the lean component. By first estimating what fraction of the body is lean and then calculating the radioactivity distribution within a given lean volume, the proper dose of radiopharmaceutical for treatment without undue toxicity can be administered on an individualized, case-by-case basis.
[0009] While resolving many of the difficulties related to the prescription of effective amounts of radiation doses, the prior art nevertheless may be improved upon.
SUMMARY OF THE PRESENT INVENTION
[0010] The present invention is directed to methods for determining the number of millicuries of radioactivity to be administered to a patient so as to establish a given centigray (cGy) dose to either the patient's lean body or the patient's total body.
[0011] According to a general method of the present invention, a parameter directed to "total body dose-lean" (TBD-lean) is utilized to account for the fact that individuals may be modeled as an outer shell of fat (where little radioantibody or radiopharmaceutical accumulation occurs) which surrounds an active lean body mass, including bone marrow. By appreciating the fact that in man there is a "lean body" within a "fat" outer shell, a formula may be used to estimate what percentage of the person is fat and what percent of the person is lean. Thereafter, the radioactivity is traced as essentially being distributed uniformly and totally through the lean component. By first estimating what fraction of the body is lean and then calculating the radioactivity distribution within a given lean volume, the proper dose of radiopharmaceutical for treatment without undue toxicity can be administered on an individual, case-by-case basis.
[0013] Initially the rate of clearance or disappearance of radioactivity from a patient is determined by direct measurement across multiple time points using a radiation detection device (such as a Nal probe or a gamma camera). This step determines changes in the radiation concentration of a particular patient over a given period of time. For example, a series of measurements, commonly seven or eight, are done over a period of a week with the first measurement made immediately following a tracer injection of the radiopharmaceutical. The time in hours is determined from the end of the tracer infusion for each measurement, resulting in a variety of values. Appropriate measurement is made of the amount of radioactive disintegration measured from the front of the patient (anterior measurements) and/or from the back of the patient (posterior measurements).
[0014] Based on these readings, a geometric mean is calculated. The geometric means may be based upon daily Nal probe measurements, but may also be based upon anterior and posterior conjugate view gamma camera imaging data or other methods of radiation detection. According to the conjugate view approach, a geometric mean is calculated for each time point by multiplying the anterior and posterior readings and determining the square root of the total figure. This mean represents an average number of counts. The background counts are subtracted for a corrected mean. The percent injected activity remaining in the body for each time point is thereafter determined by dividing the counts at a given time by the counts immediately after the tracer is injected. Thereafter, the percent of injected activity versus the calculated time from infusion is plotted on a log linear graph. With these points established on the log linear graph, a line is drawn to determine the intersection of the best fit line with the 50% injected activity line, thereby determining effective half life, or T 1/2-effective.
[0015] With T 1/2-effective thus established and the patient's body weight known, these values are cross-indexed on either a graph (the "graphical" approach) or on a table (the "tabular" approach) to determine the recommended millicuries per centigray (mCi per cGy) to be administered (activity per unit TBD or TBD-lean). (Both the graphical approach and the numerical approach represents activity per unit for total body dose [TBD] or total body dose-lean [TBD-Lean] as a function of total body or lean body mass and T 1/2-effective.) Both the graphical and numerical approaches (and their expressed quantities) are features of the present invention.
[0016] The actual amount of therapeutic millicuries is then determined by multiplying the recommended mCi per cGy by the amount of desired centigray to be administered.
[0017] While the present invention is described as having application to total body dose and total body dose-lean, the method of the present invention is also applicable to dosimetry to blood, bone marrow, and other organs and tissues such as the lung, the liver, and the kidney.
[0018] These and other features of the present invention are best understood from the following specification, drawings and examples.
BRIEF DESCRIPTION OF THE DRAWINGS
[0019]
Figure 1 is a graph illustrating the relationship of the fat component of the individual with respect to the lean component of the same individual, thus defining the "lean person within the fat person" theory of the present invention; and
Figure 2 is a graph illustrating the elimination of the radioactive element from the individual over time, with the amount of material being on the Y-axis and time being on the X-axis.
Figure 3 is a blank worksheet onto which are to be entered all necessary intermediate values based upon observations of clearance of the tracer from the body according to an alternate method of the present invention;
Figure 4 is a curve set on a graph indicating therapeutic activity per unit dose calculated from data acquired on days 0, 3, and 7 versus data acquired on days 0, 1, 2, 3, 4, 5, 6, and 7;
Figure 5 is a blank graph consisting of a log linear graph onto which pertinent elimination values are to be marked at different intervals of time;
Figure 6 is similar to the graph of Figure 4 but illustrating two series of elimination values for two sample patients;
Figure 7 is a fused image of a cross-sectional view of the central body compartment of a sample patient following administration of radiolabelled antibodies;
Figure 8 is a graph illustrating the relationship of the fat component of the individual with respect to the lean component of the same individual;
Figures 9a - 9p define a series of graphs used for determining the therapeutic mCi/cGy to be administered based on known T 1/2-effective and the patient's mass (in Kg), total body mass (in Kg) for TBD, and lean body mass (in Kg) for TBD-Lean;
Figures 10a - 10h define a series of tables used for determining the therapeutic mCi/cGy to be administered based on known T 1/2-effective and the patient's mass (in Kg), total body mass (in Kg) for TBD, and lean body mass (in Kg) for TBD-Lean;
Figure 11 is a three-dimensional graph based on the series of graphs of Figures 9a - 9p;
Figure 12 is chart summarizing the input and output data of twenty-one sample patients;
Figure 13 is a toxicity versus mCi/Kg graph with the data points of the twenty-one sample patients of Figure 12;
Figure 14 is a toxicity versus total body dose [cGy] graph with the data points of the twenty-one sample patients of Figure 12; and
Figure 15 is a toxicity versus total body dose-lean [cGy] graph of the data points of the twenty-one sample patients of Figure 12.
DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENT
[0020] According to the theory underlying the general method of the present invention, the body represents two major compartments, a ''fat'' compartment and a "lean" compartment and that the "lean" person resides within an outer shell of "fat". These related theories represent a major departure from other approaches to dosimetry. Accordingly, a calculation of the quantity of the patient which is "lean body mass" can be made. From this new mass and new shape, a new and more accurate radiation dose can be determined to the "lean body" using methods of least squares fitting of kinetic radioantibody or radiopharmaceutical clearance data and assumptions of non-uniform distribution of radioactivity between the two body compartments. From this is produced one simple assumption that all radioactivity resides in the "lean" compartment, while none resides in the fat compartment, which encases the "lean" compartment. With the further assumption that the bone marrow is part of the freely accessible "lean" compartment, a beta particle and photon dose to the lean compartment can be determined. it is further assumed in this approach that irradiation of the "fat" layers has either no significant or has little significant adverse effects on bone marrow function.
I. GENERAL METHOD
[0021] Figure 1 illustrates the relationship of the fat component of the individual with respect to the lean component. An individual can be thought of as two ellipsoids, with the length x-1 or x-2 and with y-1 or y-2. The outer ellipsoid, labelled OE, with the larger x and y dimensions represents fat plus lean mass, with a volume (in liters) approximately equal to the patient's weight (in kilograms). The inner ellipsoid, labelled IE, with the same aspect ratios, is defined in liters by the formulae:
(where height is in centimeters)
[0022] It should be understood that total Lean Body Mass could also be directly measured by CT, x-ray absorptiometry, immersion weighing, and other known methods. The total body absorbed dose is then determined for the lean body ellipsoid based on conventional calculations. it should also be understood that corrections for Compton scatter of photons from the fat compartment or some trace accumulation in the fat compartment are also possible, but need not be included in the simplest application of the present method.
[0023] The steps of the method for applying the present invention are as follows, and reference may be had throughout the following explanation to Example 1 which appears below.
[0024] A "Proposed Lean Body Radiation Dose" is determined. This is a variable and can be selected from a wide range of possibilities. The proposed lean body dose shown in the "Data Entry" of Example 1 is 75 and is based on the particular antibody used. The value 75, however, should be interpreted as being a representative range. (it is to be understood that while Example 1 is directed to the use of an antibody, the methods of the present invention may be more generally used with, any protein or compound having specificity for a target cell or a target substance, provided the protein or compound is capable of carrying a radioactive marker or label. For example, newly developed phospholipidethers having cancer-cell specificity may be radiolabelled and used in the method of the present invention.)
[0025] Thereafter, the "Patient Lean Body Mass" is determined from the formula set forth above or other methods. In Example 1, the subject was a male, and the value (in kilograms) was found to be 65.00.
[0026] The'Tracer Dose" (in mCi) represents a the amount of radioactivity (the "Tracer Dose") that is initially administered to the patient. The course and timing of the elimination of the "Tracer Dose" is thereafter followed. The course of elimination is illustrated in Example 1 under the "Whole Body Probe Data". As shown, the "Tracer Dose" was injected over a period of 40 minutes ("Start of Infusion: 3:50 PM; End of Infusion: 4:20 PM"). A whole body radioactivity probe is used to thereafter determine the amount of radioactive material still remaining in the body after certain Intervals of time. (The whole body probe is only one of several possible ways of measuring the radioactivity in the patient. Other possible methods include a gamma camera, a geiger counter, whole-body counter, etc.)
[0027] In Example 1, the test intervals are separated by approximately 24 hours, as may be seen by reference to "Data Points" 1 through 8. Specifically, counts are done using the same radiation detection device from both anterior and posterior views. This is the so-called "conjugate view approach" and allows both front and back views of the patient and determination of a geometric mean of counts. ("P Intv" refers to length of the counting in seconds; the "Bkg counts" refers to background counts.)
[0028] Thereafter, and with reference to the "Data Analysis" of Example 1, a plot illustrating the disappearance of the radiation from the patient as determined by the probe is graphed. The plot of Example 1 is represented in Figure 2 showing time intervals (in hours) along the X-axis and the amount remaining along the Y-axis. On the "Data Analysis", a calculation has been done demonstrating the percentage of radioactive material (in this instance, radioactive iodine) that remains in the patient at a given time. With 100% of the dose being present at the beginning of the study, this amount is seen as disappearing over a period of time.
[0029] By referring to a trapezoidal integration determination (on the "Dosimetry Analysis" of Example 1), the area under the curve of the elimination graph (shown as an example in Figure 2) can be determined. (This can also be done using the "Curve Fitting" approach also illustrated under "Dosimetry Analysis" which utilizes a series of curve fitting coefficients.) This represents accumulated radiation exposure to the patient. With this amount known, the "Long Term Behavior Extrapolation" ("Data Analysis") is used to provide information as to how quickly the radioactive material is leaving the body. (There are listed three "Options" listed: "last 2pts., last 3 pts., last 4 pts." This is from the tail end of the disappearance of a curve such as that shown in Figure 2. At "last 3 pts.", the extrapolated T 1/2 is 67.85 hours.)
[0030] Knowing the area under the curve and knowing, according to the provided example, that the lean body mass is 65 kilograms, a "Determination of Photo Absorbed Dose From Lookup Table" is then made. ("Lookup Table" follows "Dosimetry Analysis".) This determines what component of the dose is due to an absorbed photon in addition to the dose due to beta decay (electrons). The "Lookup Table" is photon energy specific. An example of I-131 is shown.
[0031] Now, knowing the size of the mass (in this instance, 65 kilograms) and the dimensions of the ellipsoid, the amount of radiation dose to lean body mass can be calculated. In Example 1,60% of the radiation dose to lean body mass is due to electrons and 40% is due to photons. Accordingly, to produce the exemplary 75 rads, it is necessary in this particular case to give the patient a dose of 76.6 mCi, as the radiation dose to lean body mass/mCi is 0.9785. It is coincidental that the mCi dose approximates the rad dose.
[0032] As may be seen, the object of the present invention and the described steps is to identify the estimated dose in mCi (presented under "Estimated Dose" under "Dosimetry Analysis"). Overall, the "Estimated Dose" is determined by sequential sampling (in Example 1 particular case there were eight time points) using a radioactivity detector. The necessary probe data is determined by using either a trapezoidal integration formula or a curve fitting formula. This is directed to the determination of the area under the curve which is accumulated radiation. Then, using the body size, the amount of photons absorbed versus the amount of photons not absorbed becomes known as well as the beta component.
[0033] The general method of the present invention may be more fully understood by reference to the following example.
II. MODIFIED METHOD
[0034] The method for determining the number of millicuries to be administered to a patient so as to deliver a given centigray (cGy) dose to either the patient's lean body or the patient's total body set forth above may be modified. The following steps are involved according to the modified method of the present invention:
(1) Injecting a radioactive tracer into a patient;
(2) determining radiation levels in the whole body;
(3) calculating a geometric mean;
(4) determining the percent-injected activity remaining in the body at each time point;
(5) plotting the percent-injected activity versus calculated time from infusion on a log-linear graph;
(6) determining the effective half-life (and the rate of clearance) from the log-linear graph by identifying the intersection of the best fit line with the 50% injected activity line;
(7) cross-indexing the effective half-life value with the patient's body weight (either total body mass for total body dose or lean body mass for total body dose-lean) on either a graph or on a numerical chart to identify the actual amount of therapeutic millicuries per centigray [cGy] (delivered to total body mass or lean body mass); and
(8) multiplying the determined amount of therapeutic millicuries per centigray [cGy] (delivered to total body mass or lean body mass) by the amount of desired centigray (to total body mass or lean body mass) to be administered.
[0035] These steps along with their associated substeps are set forth in detail as follows and are to be read in correlation with the several figures discussed in conjunction therewith.
DETERMINATON OF RATE OF CLEARANCE
[0036] Determining the rate of clearance of an injected dose of a particular radiopharmaceutical is critical to the determination of the amount of therapeutic dose to be administered. A person who clears the injected dose quickly would receive a relatively large therapeutic dose of the particular radiopharmaceutical drug as compared to a person who clears the injected dose less quickly. This is simply because of residence time - the longer the radiopharmaceutical is proximate to the disease site, the less need be administered. Quick clearance translates into brief exposure to the radioactive element and less effective treatment of the disease. (Other factors determine the administered radioactivity dose, including the size of the patient and the desired total centigray amount.)
[0037] Rate of clearance according to the modified method of the present invention is determined by administering an amount of a "tracer dose" to the patient. The tracer dose represents a small amount of radioactivity attached to an antibody. As noted above, the methods of the present invention are not limited to use of an antibody. Rather, any protein or compound having specificity for a target cell or a target substance, provided the protein or compound is capable of carrying a radioactive marker or label, may be used according to the various methods disclosed herein.
[0038] The particular protein (such as an antibody) or compound (such as a phospholipidether) is selected according to its specificity to a target substance (such as an antigen) or to a target cell (such as a cancer cell). In light of the known utility of antibodies and by way of example, the following discussion will be based on the use of an antibody.
[0039] The "tracer dose" (in mCi) represents the amount of radioactivity that is initially administered to the patient. (The "tracer" aspect of this dose does not refer to a trace amount of antibody, but rather to the trace amount of radioactive material attached to the antibody. The antibody mass is delivered during the stage of estimating the rate of clearance in the same amount as in therapy, however, the amount of radioactivity administered is lower to prevent toxicity to the system. Experimentation has shown that the tracer dose is, in fact, a reliable predictor of the therapeutic dose. Special measurements taken after therapy initially based upon a tracer dose has shown that the kinetics of clearance of the antibody with the tracer amount generally predict the kinetics of clearance of the therapeutic amount; in fact, these results are substantially identical.)
[0040] After administration of the tracer dose, the course of timing of the elimination of the tracer dose is thereafter followed. The tracer dose is first injected into the patient over a period of time, such as 40 minutes. Thereafter a probe is used to determine anterior and/or posterior counts, thus quantitatively demonstrating the amount of radioactivity remaining in the body after certain intervals of time. Measurements may be taken by any of several devices including a sodium-iodine probe, a gamma camera, a geiger counter, a whole-body counter, etc. Measurements are taken once approximately every 24 hours over a course of several days. Infusion stop and start times are recorded, as are counts taken for elimination over several 24-hour periods. The relevant intermediate numerical values are entered onto a worksheet such as that illustrated in Figure 3.
[0041] As an alternative to recording time points for each day of several days, as few as three (and possibly two) time points may be used to determine the shape and slope of the clearance curve of radioactivity from the body. This was verified through experimentation on twenty-eight patients who each received 700 mg total of anti-B-1 by comparing the dose calculated from eight time data points according to the computation methodology set forth above in the general method against the graphic-tabular approach and three time points of the modified method of the present invention. The comparative results are set forth in Figure 4. The correlation produced an r-value of 0.983 with a mean % difference in calculated mCi dose between the two methods being 3.33%. As illustrated in the accompanying Figure 4, the slope is 0.99 and the intercept is essentially 0. Accordingly, using the present graphic-tabular method, three probe determinations taken at 0, 3, and 7 days may be used to calculate patient dose.
[0042] Once the counts are recorded over the requisite time period, the geometric mean is obtained. This may be done by taking readings from daily Nal probe measurements, but also may be done by relying upon readings from anterior and posterior conjugate view gamma camera imaging. When the latter approach is used, a geometric mean is obtained for each set of recorded anterior and posterior counts (representing an individual time point) is determined by the following formula:
The determined geometric mean is not corrected for radioactive decay. Once the geometric mean is known, net geometric mean counts are calculated by subtracting background counts according to the following formula:
For example, if the background count is 100 cpm and the patient's count is 2000 cpm, then the net counts to the patient would be 1900 cpm.
[0043] Thereafter, the percent-injected activity remaining in the body at each time point is determined by forming a ratio to the geometric mean at the initial time point (again, not corrected for radioactive decay) according to the following:
[0044] Once the percent-injected activity for each time point is known, these values are entered into a graph to determine total body effective half life. Figure 5 is a blank graph consisting of a log linear graph onto which the pertinent values are to be marked. The percent-activity is read along the Y-axis (log scale) and the time from injection (in hours) is read along the X-axis (linear scale).
[0045] Figure 6 is the graph of Figure 5 now completed and showing the relevant values of two patients. Patient "A" is denoted by a series of eight open boxes representing measurements of percent-injected activity recorded over a period of 160 hours. Patient "B" is denoted by a series of eight closed circles also representing measurements of percent injected activity recorded over the same period of time. Lines are drawn through the respective series of open boxes or closed circles to establish the respective curves.
[0046] The effective half-life for each patient is determined by identifying the point at which the respective curves intersect the 50% injected activity level, indicated by a horizontal line on the charts of both Figures 5 and 6. This point represents the effective half-life, or T 1/2-effective. Given, for example, Patient A, T 1/2-effective is 88 hours, while T 1/2-effective for Patient B is 47 hours. Obviously, Patient A clears the injected dose more slowly than does Patient B.
TOTAL BODY DOSE VERSUS TOTAL BODY DOSE-LEAN
[0047] The present invention improves on the known techniques of determining the optimal dose for administration of therapeutic radiopharmaceuticals in several ways. One such improvement rests in the unsettling of the previously-held notion that doses of therapeutic radiation could be determined based on patient weight. This notion fails to take into account several variables, including "fat" versus "lean" compartments and the related effects of "total body dose" versus "total body dose-lean".
[0048] The body represents two major compartments, a "fat" compartment and a "lean" compartment. The corollary to this is that the "lean" person resides within an outer shell of "fat". These related theories represent a major departure from other approaches to dosimetry. Accordingly, a calculation of the quantity of the patient which is "lean body mass" can be made. From this new mass and new shape which essentially isolates the "lean" from the "fat", a new and more accurate radiation dose can be determined to the "lean body" using methods of least squares or graphical fitting of kinetic radioantibody clearance data and assumptions of non-uniform distribution of radioactivity between the two body compartments.
[0049] Figure 7 demonstrates the significance of distinguishing between "lean" and "fat" body compartments. Figure 7 is a "fused" image of a cross-section of a patient following administration of radiolabelled antibodies. The image is produced by a fusion computer program that superimposes a CT image slice corresponding to a SPECT image slice. Details of this procedure and its application are set forth in an article by K.F. Koral et al. and entitled CT-SPECT FUSION PLUS CONJUGATE VIEWS FOR DETERMINING DOSIMETRY IN IODINE-131-MONOCLONAL ANTIBODY THERAPY OF LYMPHOMA PATIENTS (J. Nucl. Med., Vol. 35, No. 10, October 1994, pps. 1714-1720). Generally, Figure 7 illustrates a central body compartment that includes the major organs such as the kidneys and spleen. The individual images are scaled by a computer so they substantially overlap when superimposed. The lighter areas are areas of relatively high amounts of radioactivity, while the darker areas are areas of low radioactivity.
[0050] With respect to Figure 7, a tumor, T, is shown in close association with the right kidney, labelled Rt K. Other organs illustrated include the aorta, A, the left kidney, Lf K, and the spleen, Sp. The patient's external body outline, labelled O, is illustrated, having thereupon a marker, M, to demonstrate the position of the body outline O. The outline O is the outer boundary of the patient and therefor represents the air-skin interface. The black area is mainly non-lean tissue, with the gray areas being the central area or the leaner body mass. As illustrated, there is a considerable amount of radioactivity in the vascular or lean component where antibody presence is the greatest. There is comparatively little radioactivity in the non-lean tissue, as illustrated by the black color. The patient illustrated in Figure 7 is a relatively large person having an excess amount of body fat. The body outline O would be closer to the internal organs on a thinner person.
[0051] While clearly illustrating the differences in uptake of the radiolabelled antibody between the lean and non-lean compartments, Figure 7 also demonstrates how it is generally not possible to target the disease site itself. While careful selection of a particular antibody will minimize cross-reaction with normal tissue, interaction (specific or non-specific) with non-disease tissue invariably results, in that as antibodies are directed to the tumor through blood vessels, the same vessels will naturally transport the antibodies in places other than to the disease site. Figure 7 also illustrates the simple assumption of the present invention that all (or substantially all) radioactivity resides in the "lean" compartment, while none (or virtually none) resides in the "fat" compartment, which encases the "lean" compartment. With the further assumption that the bone marrow is part of the freely accessible "lean" compartment, a beta particle dose and photon dose to the "lean" compartment can be determined. These estimations are important, in that the total amount of energy deposited in an individual as a result of radioactive decay is the "radiation dose" which is adjusted per unit weight for the particular individual or tissue and for a particular radioactive material. A specific example is the radioactive material I-131 which is both a beta emitter and a gamma emitter.
[0052] Following injection of an antibody labelled with I-131, for example, the central "lean" compartment of the body emits both beta and gamma particles. The beta particles are more or less confined within the compartment, while only some of the gamma particles are so confined. The extent to which the gamma particles are confined depends on the sizes of the "lean" and "fat" compartments. Some of the gamma particles strike some fat tissue and are scattered, returning to the "lean" compartment. Accordingly, not only does accurate quantification of the "lean" and "fat" compartments assist in eliminating reliance on the pure weight of a body in determining dose administration, an understanding of these compartments with respect to the individual patient also aids in determining, with greater accuracy, the "tracer dose" and its elimination.
[0053] Accordingly, it may now be understood that total body dose (TBD) assumes that all radioactivity is uniformly distributed throughout the patient's total body mass, and that all beta/electron energy is absorbed in the total body mass. TBD calculations for photon energy deposition are made from absorbed fractions of emissions of the radioactive material (for example, I-131) in the ellipsoid of mass equal to the total body mass. Conversely, total body dose - lean (TBD-Lean) is modeled as a lean-body mass ellipsoid surrounded by a fat-layer ellipsoid shell. TBD-Lean assumes that all radioactivity is uniformly distributed throughout the patient's lean body mass, since there is little tracer distribution to fat. in the TBD-Lean model, all beta/electron energy is absorbed in the lean-body mass, and photon energy is absorbed in lean-body mass ellipsoid volume. This said, it is clear that the more obese the patient, the more important dosage be based on the TBD-Lean model. Conversely, dosage for a relatively thin person could be reliably based on the TBD approach. However, regardless of the approach, the present method of determining optimal radiation dose could be used with either the TBD or the TBD-Lean model, with the latter model providing the better determination, particularly in the case of the obese patient.
[0054] Figure 8 illustrates the relationship of the fat component of the individual with respect to the lean component and accordingly is a visually simplified version of the actual section shown in Figure 7. An individual can be thought of as two ellipsoids, with the length x-1 or x-2 and with y-1 or y-2. The outer ellipsoid, labelled OE, with the larger x and y dimensions represents fat plus lean mass, with a volume (in liters) approximately equal to the patient's weight (in kilograms). The inner ellipsoid, labelled IE, with the same aspect ratios, is defined in liters by the following formulae that determine "lean body mass" (LBM):
It should be understood that total LBM could also be directly measured by CT, x-ray absorptiometry, immersion weighing, and other known methods. The total body absorbed dose is then determined for the lean body ellipsoid based on the following methods. It should also be understood that corrections for Compton scatter of photons from the fat compartment or some trace accumulation in the fat compartment are also possible, but need to be included in the simplest application of the present method. Following this general guideline, the method of determining the patient's LBM of the above-described general method is followed.
DETERMINATION OF THE WHOLE BODY DOSE
[0055] With the effective half life or T 1/2-effective determined from tracer study, the whole body dose may be calculated. By "whole body dose", it is meant that these calculations are made for the whole body or for the lean body mass component of the whole body.
[0056] The calculations of the whole body dose according to the modified method are based on the assumption that the radioantibody is uniformly distributed throughout the patient (or the lean body mass compartment) following tracer injection and that the tissues are of uniform water density. Accordingly, determining the patient's mass (or lean body mass as set forth above) determines the assumed water content and patient volume for dosimetric calculations.
[0057] The "total body residence time" is an integral of the time activity curve for the total body divided by the injected activity according to the following formula:
[0058] The relative contributions of electron and photon radiation are summed to produce the total body radiation dose ([cGy]/mCi) administered. The formula for this determination is as follows, where the total body dose is the sum of electron energy plus photon energy deposited in an ellipsoid having a mass mTB:
[0059] This equation can be solved for AT the therapy activity in mCi to impart a given total body dose, DTB.
[0060] These individual equations could be solved manually. However, it is preferred that the equations be reduced to graphical and tabular (numerical chart) formats, as illustrated in Figures 9a - 9p (for use in the graphical method) and Figures 10a - 10h (for use in the tabular method). A three-dimensional representation of the graphical method is illustrated in Figure 11. Such reductions greatly reduce the need for calculation and allow the method to be practiced without the need for complex computation.
[0061] To use the graphs of Figures 9a - 9p, the known effective half-life is cross-indexed with the patient's weight. The amount of therapeutic millicuries/cGy (for either total body dose or total body dose-lean) is set forth along the Y-axis, and the physician reads along the graph to the left to make this determination. To use the tables of Figures 10a - 10h, again the known effective half-life is cross-indexed with the patient's weight. The value at the intersection of the weight and T 1/2-effective is the amount of therapeutic millicuries/cGy.
[0062] Once the amount of therapeutic millicuries/cGy is established, this value is multiplied by the amount of desired centigray to be administered to treat a particular disease. These amounts are well known to those skilled in the art, but are not uncommonly in the 50-90 cGy range for whole-body dose.
[0063] Both the general and modified methods of the present invention may be more fully understood by reference to the following example.
EXAMPLE 2
[0064] A phase-I dose-escalation trial of I-131 labelled B1 antibody for the treatment of patients with non-Hodgkin's lymphoma was undertaken using a dose-escalation scheme designed around increasing levels of total body radiation dose. The overall results of the studies of 21 patients are set forth in the table of Figure 12. (The study began with 34 patients, hence the listing in the left-hand column of patient numbers with some patient numbers missing. Some of the missing patients, i.e., nos. 3, 11, 12, 17, 18, 20-23, 25, 26, 30, and 33, were bone marrow transplant patients or were patients who were subsequently not treated for various reasons, e.g., development of human antimouse antibody.)
[0065] Hematological toxicity was the major toxicity observed in the 21 patients studied that received radioimmunotherapy. Patients were treated with radioimmunotherapy doses calculated from tracer dosimetry studies (Nal probe) to deliver doses to the whole body ranging from 25 to 85 cGy. Hematological toxicity after treatment was assessed by the NCI common criteria, grades 0-4. Nine patients had no toxicity, 5-grade-1, 3-grade-2, 2-grade-3, and 2-grade-4 (grade 4 is the most severe). Total body dose was estimated by modeling the patient as a uniform activity distribution in an ellipsoid for the purpose of calculating the energy absorbed fraction of photons from I-131 decay. The parameter of the present invention, the Total Body Dose-Lean was introduced to account for the fact that obese patients can be modeled as an outer shell of fat (with little radioantibody accumulation) surrounding the active lean body mass. Irradiation of the fat layer would presumably have little effect on hematologic toxicity. Blood clearance and dose was determined from actual tracer blood samples. Marrow residence time was estimated using the assumption that specific activity in marrow is 30% of the specific activity in blood. Resulting correlation between estimated dose parameters from the tracer studies and hematological toxicity grade were as follows:
| Dose Parameter | r-value | p-value (N=21) |
| blood-dose | 0.337 | 0.146 |
| marrow-dose | 0.421 | 0.064 |
| mCi/kg | 0.270 | 0.236 |
| TBD | 0.430 | 0.052 |
| TBD-lean | 0.523 | 0.015 |
[0066] The improvement according to the present invention is clearly observable by reference to the graphs of Figures 13 through 15. With respect first to the graph of Figure 13, dosage based on simple mCi per Kg of patient weight is set forth. The toxicity level correlates poorly with mCi/Kg due to the assumption of uniform distribution in the patient's total body mass, and also clearance kinetics are not taken into account. Figure 14 discloses a graph similar to that of Figure 13, but based upon total body dose (TBD) [cGy]. As illustrated, the toxicity grade from the administered dose correlates better with TBD than for the less exact method that produced the graph of Figure 13. Finally, Figure 15 discloses a graph similar to those of Figures 13 and 14, but illustrating results produced from reliance on the total body dose-lean (TBD-Lean) [cGy] method. The grade of toxicity from the administered dose is best predicted by the TBD-Lean method than that for the method based on total body dose (shown in Figure 14) and also the method based simply on mCi/body weight (shown in Figure 13).
[0067] Those skilled in the art can now appreciate from the foregoing description that the broad teachings of the present invention can be implemented in a variety of forms. Therefore, while this invention has been described in connection with particular examples thereof, the true scope of the invention should not be so limited since other modifications will become apparent to the skilled practitioner upon a study of the drawings, specification and following claims.
1. A method of establishing the optimal effective radiation dose for treatment of disease
in a patient, said method comprising the steps of:
establishing the rate of clearance of a tracer dose from the patient's body;
identifying a numerical value based on said rate of clearance;
determining the actual amount of therapeutic mCi per cGy based on said numerical value by cross-indexing said numerical value with the patient's body weight; and
multiplying said actual amount of therapeutic mCi per cGy by the desired amount of cGy to be administered.
2. The method of establishing the optimal effective radiation dose of claim 1, including
the further step of identifying the effective half-life value of said tracer dose
in the patient based on said rate of clearance.
3. The method of establishing the optimal effective radiation dose of claim 2, including
the further step of determining said actual amount of therapeutic mCi by cross-indexing
said effective half-life value with the patient's body weight.
4. The method of establishing the optimal effective radiation dose of claim 3, including
the further step of cross-indexing said effective half-life value with the patient's
total body mass for a total body dose.
5. The method of establishing the optimal effective radiation dose of claim 4, including
the further step of cross-indexing said effective half-life value with the patient's
lean body mass for a total body dose-lean.
6. The method of establishing the optimal effective radiation dose in mCi for treatment
of disease in a patient, said method comprising the steps of:
establishing the rate of clearance of a tracer dose from the patient's body;
identifying the effective half-life value of said tracer dose in the patient based on said rate of clearance;
determining the actual amount of therapeutic mCi per cGy based on the effective half-life of said tracer; and
multiplying said actual amount of therapeutic mCi per cGy by the amount of desired cGy to be administered,
wherein the method optionally further includes one or more of the following steps:determining said actual amount of therapeutic mCi by cross-indexing said effective half-life value with the patient's body weight;
cross-indexing said effective half-life value with the patient's total body mass for a total body dose;
cross-indexing said effective half-life value with the patient's lean body mass for a total body dose-lean;
injecting a radioactive tracer into the patient and determining a radiation level
for said injected radioactive tracer and optionally then calculating a geometric mean
based on said determined radiation level,
wherein said geometric mean may be based upon Nal probe measurements and/or upon anterior
or posterior conjugate view gamma camera imaging data;
determining the percent-injected activity remaining in the patient's body across a plurality of time intervals and optionally also then plotting said percent-injected activity versus calculated elimination time from infusion on a log-linear graph, and wherein if said log-linear graph includes a 50% injected activity line, optionally including the further step of determining said effective half-life from said log-linear graph by identifying the intersection of the best fit line with said 50% injected activity line;
cross-indexing said effective half-life with the patient's body weight on a graph having a first axis and a second axis substantially perpendicular to said first axis, said first axis having increments of Rx mCi/cGy and said second axis having increments of body mass to identify the actual amount of therapeutic mCi; and
cross-indexing said effective half-life with the patient's body weight on a table having a first axis and a second axis substantially perpendicular to said first axis, said first axis having increments of body mass and said second axis having increments of effective half-life to identify the actual amount of therapeutic mCi.
7. A method of establishing the optimal effective radiation dose for treatment of disease
in a patient, said method comprising the steps of:
identifying the effective half-life value of a tracer in the patient; and
determining the actual amount of therapeutic mCi based on the effective half-life of said tracer,
wherein the method optionally further includes multiplying said actual amount of therapeutic mCi per cGy by the amount of desired cGy to be administered.8. The method of establishing the optimal effective radiation dose of claim 1, wherein
said step of determining the actual amount of therapeutic mCi per cGy is also based
on the patient's total body mass or the patient's lean body mass.
9. Use of an apparatus for establishing the optimal effective radiation dose in mCi for
treatment of disease in a life form comprising means for establishing the rate of
clearance of a tracer dose from the life form, means for identifying the effective
half-life value of said tracer dose in the life form based on said rate of clearance,
means for determining the actual amount of therapeutic mCi per cGy based on the effective
half-life of said tracer, and means for multiplying said actual mount of therapeutic
mCi per cGy by the amount of desired cGy to be administered.
10. An apparatus for establishing the optimal effective radiation dose in mCi for treatment
of disease in a patient, said apparatus comprising:
means for establishing the rate of clearance of a tracer dose from the patient's body;
means for identifying the effective half-life value of said tracer dose in the patient based on said rate of clearance;
means for determining the actual amount of therapeutic mCi per cGy based on the effective half-life of said tracer; and
means for multiplying said actual amount of therapeutic mCi per cGy by the amount of desired cGy to be administered.